UNDERSTANDING RHEUMATOID ARTHRITIS IN AYURVEDIC PERSPEC- TIVE AND ITS MANAGEMENT- A REVIEW ARTICLE

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1 Review Article International Ayurvedic Medical Journal ISSN: UNDERSTANDING RHEUMATOID ARTHRITIS IN AYURVEDIC PERSPEC- TIVE AND ITS MANAGEMENT- A REVIEW ARTICLE Dhakar Jyoti 1 Mishra Pramod kumar 2 Soni Anamika 3 Sharma Brahmanand 4 1 MD Scholar, 2 MD Ph.D (Ay.) Associate Professor & HOD, 3 MD (Ay.) Assistant Professor, 4 MD Ph.D (Ay.) Assistant Professor PG Department of Kayachikitsa, University College of Ayurveda, Dr. S. R. Rajasthan Ayurveda University, Jodhpur, Rajasthan, India ABSTRACT As per Ayurveda, Vitiated Ama and Vata simultaneously lodge in Trika and Sandhi leading to Shotha(Swelling), Stabdhata(Stiffness) in the body and joints. The condition is known as Amavata. This condition is very similar with the disease Rheumatoid Arthritis described in modern medicine. Rheumatoid arthritis is a chronic multisystem disease of unknown cause, although there are a variety of systemic manifestation, the characteristic feature of RA is persistent inflammatory synovitis, usually involving peripheral joints in a symmetric distribution. The prevalence is approximately 0.8% of the population (Range 0.3% to 2.1%). Women are affected approximately three times more than men. The onset is most frequent during 4 th and 5 th decades of life, with 80% of all patients developing the disease between the ages of 35 and 50. Mandagni(Weak digestive power), Guruahara(Heavy meal), Avayayama (Sedentary life style)etc are the etiological factors of Amavata.Pratyatma (Cardinal) LaksanaofAmavataareGatrastabdhata (Stiffness in body), Sandhishula (Arthralgia), Sandhishoth (Joint swelling), Sparshasahyata(Tenderness in joints).upadrava Complications) are stated as- Jadya, Antrakujana, Trit, Chardi, Bahumutrata, Shula, Samkocha, Khanjata etc. In modern medicine Steroides, Analgesics, Anti Inflammatory drugs, DMRD are used which give only symptomatic relief and have serious side effects. Langhana, Svedana, Tikta, Katurasasevan, Dipana, Virechana, Snehan, Basti, RukshaSvedaetc supported by most acharya for the treatment of Amavata. Keywords:RheumatoidArthritis, Stabdhata, Synovitis, Sandhishotha, Amavata INTRODUCTION Etymology:- The words Ama and Vata join to form Amavata.The predominance of these two factors in the pathogenesis of this disease are already suggested in following phrase. The association of VataDosa with Ama is termed as Amavata. The propulsion of Ama by Vata in the whole body is illustrated with this derivation. Due to indigestion, Ama is produced and along with Vata it causes a well-known disease entity. The improperly formed Annarasa is known as Amavata. 1 So all the above mentioned derivation emphasizes that the disease is based on Ama and Vata mainly which clarifies the importance of these two. Definition:-The condition in which Vitiated Ama and Vata simultaneously lodge in Trika and Sandhi(Joints) leading to Stabdhata(Stiffness) of the body is known as Amavata. 2 In modern era it is correlated

2 506 with Rheumatoid arthritis. Rheumatoid arthritis is a chronic multisystem disease of unknown cause, although there are a variety of systemic manifestation, the characteristic feature of RA is persistent inflammatory synovitis,usually involving peripheral joints in a symmetric distribution.the potential of the synovial inflammation to cause cartilage destruction and bone erosion and subsequent changes in joints integrity is the hallmark of the disease. 3 Distribution And Prevalence:-The prevalence is approximately 0.8% of the population (Range 0.3% to 2.1%)women are affected approximately three times more than men. 4 The prevalence increases with age and sex, difference diminish in the older age group. RA is seen throughout the world and affects all races. The onset is most frequent during 4 th and 5 th decades of life, with 80% of all patients developing the disease between the ages of 35 and Basic Concept:-The main factors of disease are Ama, Agni, Vata and involvement of Sandhi. Ama:-In Ayurvedic classics, Ama is a stage which is due to hypo functioning of Pachakagni i.e. Mandagni as a consequence of Ahara, which can t be digested properly. This undigested food material remains as an intermediate product of digestion in Amashaya. It is a type of toxic material, which is called Ama is strong enough to cause inflammation in the various body parts Etiology of Amavata:-Mandagni(Weak digestive power), Guruahara (Heavy meal), Avayayam (Sedentary life style),viruddhaahara(incompatible food), ViruddhaChesta. 6 Sign & Symptoms of Amavata:- AcharayaMadhavkara has clearly stated the Rupas(sign & symptoms)of Amavata in MadhavNidana. The PratyatmaLaksana(Main symptoms) aregatrastabdhata, Sandhishula, Sandhishoth, SparshasahyataandSamanyaLaksana(General symptoms) are Angmarda, Aruchi, Trishna, Alashya, Gaurav,Jvara, Apaka, Angasunnata. 7 In modern science, symptoms of RA are Anorexia, weightloss and fatigue, stiffness and pain in joints(athralgia) are the most common symptoms that occurs throughout the disease course and many precede the assets of articular symptoms by weeks or months. Complications of Amavata:-In MadhavNidana and AnjanaNidana the Upadrava(complications) are stated as- Jadya(Stiffness), Antrakujana(Blotting), Trit(Dypsia), Chardi(Chardi), Bahumutrata(Polyuria), Shula(Pain), Samkocha(Contraction),Khanjata(Limping) etc. 8 In modern science complication of RA are septic arthritis, amyloidosis, pain and swelling behind knee may be caused by extension of inflamed synovium into the popliteal space called as Baker s cyst. 9 Samprapti of Amavata:-When a person of sedentary habits with hypo functioning digestive mechanism indulge in incompatible diet and regimen (Virrudhaaahara vihar) or does physical exercise after taking fatty food the Amais formed and propelled by Vayuand receahes the site of Sleshma.Where this Amarasa, get much vitiatied by Vata, Pitta, and Kapha& then itis circulated (all over the body) through the vessels (Dhamini). It then takes on accumulates in the small channels& joint pores. It renders the patients weak and produces a feeling of heaviness& stiffness in whole body. This substance named Ama is the cause of so many distressing diseases. When this aggravated Ama simultaneously afflicts the (pelvic and shoulder) girdles, and other joints making the body stiff, this condition is known as Amavata. 10 SampraptiGhatakofAmavata:- 11

3 Dosha Tridoshajamainlyvata (Vyana, Samana, Apana) andkapha (Kledak, Bhodhak, Sleshak). Dushya- Rasa, Mamsa, Asthi, Majja. Upadhatu- Snayu, Kandara. Srotodusti Sanga, Vimargagaman. Diagrammatic Presentation of Samprapti of Amavata:- 12 Nidanasevan AgnimandhyaTridoshaPrakopa Amotpatti AccumulationofAmainSleshmasthan Ama in Hridhya&Dhamni Further Vitiation ofamaindhamanibyvata, Pitta andkapha NanavarnaAtipichhilaAma Udbhavsthana (origin) AmaPakvasayotthaAmasaya- ChiefsiteofproductionofAma. Pakvasaya MulaSthanofVata. Adhisthan Sandhi (Whole body) VyadhiSheabhava Mainly Chirkari Sroto-Abhishyanda (Rasa, Asthi, Majja Mainly RasavahiSrotas) HridyagtaSarirgataTrikaSandhigata Amavata Diagnosis of RA:-In diagnosis of any disease following basic tools are important:-cardinal sign and symptoms, laboratory findings, any establish criteria, Study of the differential Diagnosis. American rheumatism association criteria (1988 revision) for diagnosis RA is as follows- 13 (a) Clinical:-Morning stiffness(> 1 hr.),arthritis of 3 or more joints area, Arthritis of hands joints, Symmetrical Arthritis, Rheumatoid nodules, Rheumatoid factor, Radiological changes.diagnosis of RA should be made with above mentioned four or more criteria. (b) Investigations of RA:-Anti-CCP, ESR, CRP, RA factor,hb, MRI, Radiographs, Serological tests, Synovial Analysis. Chikitsa of Amavata:-AcharyaCakradutta was first who described the line of treatment and drugs for Amavata.Further texts Bhavapraksha and Yogratnakar followed the same guideline.langhanasvedana, Tikta, Katurasasevan, Dipana, Virechana, Snehan, Basti, RukshaSvedaetc supported by most acharya for the treatment of Amavata. 14 Some Herbal Preparations useful in Amavata:- 15 Fomentation should be Ruksha (dry) type using bags of heated sand, or Upnahas (applying poultices) may become even these without use of fats. For the patient of Amavata suffering from thirst, drinking water prepared by boiling Panchkola in water is said to be beneficial. 507

4 Yusa (soup) prepared from either dried Mulaka or Panchamula or Kanjika added with powder of Sunthi may also be given. Shatapuspa (Ancthumsowa), Vacha (Acoruscalamus),Vishva (Zingiberofficinale), Gokhshura (Tribulusterrestris), bark of Varuna (Crataevanurvala), Punarnava (Boerhaviadiffusa),Devdaru (Cedrusdeodara), Prasarini,(Pistaciafoetida)and Madanphala (Randiaspinosa)- all equal in quantity macerated in sukta or Kanjika and applied as Upnaha(Poultice) is ideal. Chitraka (Plumbagozeylanica), Katuka(Picrorhizakurroa), Patha (Cissampelospareira)Kalingra, Ativisha (Aconitum hetrophylum), Amrta (Tenosporacordifolia), Devdaru (Cedrusdeodara),Vacha (Acoruscalamus) Musta (Citrus rotundus), Nagara (Zingiberofficinale),and Abhya (Terminalliachebula), should be made into fine powder and consumed with warm water daily. This is the ideal medicine for Amavata. Decoction of Shathi, Shunthi (Zinzeberofficinale), Abhaya (Terminalliachebula), Ativisha (Aconitum heterophyllum) and Amrita (Tinosporacordifollia) is a good digestive in Amavata. Decoction of Punarnva (Boerhaviadiffusa), Brhati (Solanumindicum), Vrdhmana (Erand) (Ricinuscommunis), Phanijjaka (Origanummajurana), Murva (Marsdeniatenacissima) and Shigrudruma (Moringaoleifera) is to be used. Bathing the painful part(joints)with decoction of Eranda(Ricinuscommunis), is beneficial, so also licking(powder of) Pathya (Terminalliachebula), added with and Am- 508 rita (Tinosporacordifollia)) or consuming Guggulu (Commiphoramukul) along with cows urine or consume paste of Vishva(Zingiberofficinale) and Alambusa or of Tila(Cessamumindicum) andvishva(zingiberofficinale)all are helpful. Decoction of Vishva(Zingiberofficinale),Pathya (Terminalliachebula),and Amrita (Tinosporacordifollia)added with Kausika(Guggulu)(Commiphoramukul ) consumed warm relieve the pain of the waist, knee and back. Pippali (Piper longum), Pippalimula (Piper longum), Chavya (Piper retrofractum), Chitraka (Plumbagozeylanica)and Nagar(Zingiberofficinale) made into decoction should be consumed for cure of Amavata. Paste of Sunthi(Zingiberofficinale) and VishvaUsadhi added to the decoction of Varsabhu(Punarnva) (Boerhaviadiffusa)and consumed for seven days cure Amavata. Chitaraka(Plumbagozeylanica), Indrayan (Citruluscolocinthesia)Patha (Cissampelospareira) Katuka (Picrorhizakurroa), Ativisha (Aconitum hetrophyllum) and Abhya(Terminalliachebula)made into fine powder should be administered with warm water for curing Amavata. To win over/defeat the mighty elephant called Amavataroamingall over the body only one (Keshari-lion) called ErandaTaila(Castor-oil) is enough. 16 Leaves of Aragwadha(Cassia fistula) fried in Katutaila (mustered oil) consumed before might meals makes the person free from Ama. Decoction of Shunthi(Zingeberofficinale) and Gokhsura(Tribulusterresteris) con-

5 509 sumed in the morning daily relieves pain of the waist. Erandatail cooked with the juice of Prasarini (Pitersiafoetida) and consumed mitigates all the Doshas and the best to cure diseases arising from Kapha. Classic Ayurvedic formulations helpful in Amavata:- 17 Swarasa:-Rasna, Prasarini, Nirgundietc. Kwath:-Rasnasaptak, Rasnadashmoola, Dasmulyadietc. Churna:-Ajmodadi, Badwanal, Vaisvanar,Pachcholaetc. Vati:-Sanjivini, Agnitundi,AmavatariVatietc. Guggulu:-Singhnaad, Keshor, Rasnadi, AmritadiYograajetc. Rasa:-Amavatavidhvansan, Samirpannag, Amavatarietc. Asav: Arista:-Amritarista, Dashmoolarista, Devdarvyadietc. Swedan:-LavanSwedan, BalukaSwedanetc. Diet 18 :- Patients should be given Barley, Punarnava, Garliac, Ginger, along with substances containing wheat and small amount of rice. Fresh buttermilk with Trikatu is advisable.castor oil is beneficial, two teaspoons of castor oil in Ginger tea every day is advised. Avoid Vata and Kapha increasing foods like Curds, Cheese, Fruits having cold potency(like Banana, Guava, and Cucumber), cold drinks, and working in damp and cold atmosphere. CONCLUSION Thus from above description it can be concluded that in Amavata there is vitiation of Ama along with Vata as major. Pathological factor caused by the excess use of fatty & heavy meals, sedentary life style & heavy exertion just after heavy meals. Stiffness & pain in joints are major symptoms along with other inflammatory systemic manifestations. Modern medicine has no effective& specific treatment. Steroids, DMRD s & other drugs used for this condition are having serious side effects.the condition can be well managed with Ayurvedic drugs & regiments like Langhana, Pachna, Swedana& use of various drugs formulation as described as one & more over the therapy is free from any adverse effects. REFERENCES 1. Advances in Ayurvedic medicine, Disease of the Joints(Vol.5), RastogiSanjeev, Prof. Singh R.H., Publisher ChaukhambhaVisvabharti, First Edition 2005, page no MadhavNidana; Madhavkara(vol.5) Shastri S.,UpadhyayY.N., Chaukhambha Sanskrit Sansthan, Varanasi Reprint Page no Harrison principle of internal medicine(19 no Harrison principle of internal medicine(19 no Harrison principle of internal medicine(19 no MadhavNidana; Madhavkara(vol.1) (English Translation) Singhal et.al. Chaukhambha Sanskrit Pratisthan, Delhi. Page no MadhavNidana; Madhavkara(vol.5) Shastri S.,UpadhyayY.N., Chaukhambha Sanskrit Sansthan, Varanasi Reprint Page no MadhavNidana; Madhavkara(vol.5) Shastri S. UpadhyayY.N., Chaukhambha Sanskrit Sansthan, Varanasi Reprint Page no. 511.

6 9. Harrison principle of internal medicine(19 no MadhavNidana; Madhavkara (vol.1) (English Translation) Singhal et.al. Chaukhambha Sanskrit Pratisthan, Delhi. Page no Kaya chikitsa, Sharma Ajay Kumar(vol.2), ChaukhambhaOrientalia, Varanasi, Reprint edition 2009; page no Kaya chikitsa, Sharma Ajay Kumar(vol.2), ChaukhambhaOrientalia, Varanasi, Reprint edition 2009; page no CharakSamhita (English Translation) Sharma R.K., Dash Bhagwan(vol.2) Chaukhambha Sanskrit series Varanasi, Reprint edition 2008.Page no Chakradutta (English translation) Sharma P.V. Chaukhambha Publishers, Varanasi.Third edition 2002 Page no Bhavprakash of Bhavmishra, Prof. Murthy K.R. Shrikantha,(vol.2) Krishnadas Academy, Varanasi, First edition 2000, Page no Bhavprakash of Bhavmishra, Prof. Murthy K.R. Shrikantha,(vol.2) Krishnadas Academy, Varanasi, First edition 2000, Page no Chakradutta (English translation) Sharma P.V. Chaukhambha Publishers, Varanasi.Third edition 2002 Page no Kaya Chikitsa, Dr. RanadeSubhash, Published Reprint 2006, Chaukhambha Sanskrit Pratisthan Page no CORRESPONDING AUTHOR Dr. JyotiDhakar MD Scholar PG Department of Kayachikitsa University College of Ayurveda Dr. S. R. Rajasthan Ayurveda University, Jodhpur, Rajasthan, India Source of support: Nil Conflict of interest: None Declared 510